High Flow Nasal Cannula and High Velocity Nasal Insufflation as a Goal-Concordant Support Tool for Dyspnoea Relief in Palliative and End of Life Care

Abstract

Background: Dyspnoea is a prevalent and distressing symptom experienced by patients with both advanced respiratory and non respiratory diseases approaching the end of life. Despite widespread use of pharmacological and non pharmacological interventions, symptom control is often incomplete. Some therapies may compromise comfort, communication, or alignment with patient goals of care. High flow nasal cannula (HFNC) therapy, including high velocity nasal insufflation (HVNI), has emerged as a potential option for relieving breathlessness while preserving patient interaction and dignity.

Scope: This systematic literature review evaluates international published evidence on the use of HFNC and HVNI in palliative and end of life care, focusing on dyspnoea relief, patient comfort, tolerance, and ethical considerations. Both malignant and non malignant disease populations, inpatient and community settings, and all age categories are included.

Results: Twenty seven eligible publications were identified following database screening and eligibility assessment. Across study types, HFNC use was consistently associated with reductions in subjective dyspnoea, improved comfort, and better tolerance compared with conventional oxygen therapy or mask based NIV. Several studies reported preservation of oral intake, communication, and family interaction. A large randomised controlled trial (RCT) demonstrated superior dyspnoea relief with HFNC compared with conventional oxygen therapy (COT) in palliative patients with do not intubate (DNI) status. Evidence regarding survival impact remains limited, available data suggest that HFNC was used primarily for symptom relief rather than life prolongation.

Discussion: Both HFNC and HVNI have been successfully implemented as a comfort focused respiratory support option, particularly in hypoxemic cohorts. However, heterogeneity in study design, outcome measures, and patient populations limits generalisability to undifferentiated respiratory failure. Clinician uncertainty regarding initiation, continuation, and withdrawal of HFNC at the end of life remains.

Conclusion: Current evidence supports HFNC and HVNI as valuable interventions for dyspnoea management in palliative care, across multiple disease types and age ranges internationally. Each patient should receive a reactive palliative consultation when medical team believe mortality is indicated. Further prospective research and standardised guidance are needed to support goal concordant clinical decision making with opportunity to investigate value of HVNI in undifferentiated respiratory distress populations.